Fillable NOTICE OF FACILITY CARE (RBC Insurance)

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NOTICE OF FACILITY CARE (RBC Insurance)

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The NOTICE OF FACILITY CARE (RBC Insurance) form is 2 pages long and contains:

  • 1 signature
  • 8 check-boxes
  • 34 other fields

Country of origin: CANADA
File type: PDF

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Yes If yes,
complete below:
Name of Company
Weekly/Monthly
Amount of Benefit
Waiting Period
for Benefits
_______________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
_________________________________ ____________________ ____________________
_________________________________ ____________________ ____________________
_________________________________ ____________________ ____________________
RBC Life Insurance Company
4435 Stn A
Toronto, ON M5W 5Y8
NOTICE OF FACILITY CARE
CLAIMANT’S STATEMENT (please print)
Full Name ______________________________________________________________________________________
Date of Birth
__________________________________________ Policy Number _____________________________
Home Address __________________________________________________________________________________
Telephone Number ________________________________________
Power of Attorney Granted to (
please attach proof of Power o f Attorney if applicable) ________________________________
Address of Power of Attorney _______________________________________________________________________
Telephone Number of Power of Attorney _______________________________________________________________
Diagnosis _______________________________________________________________________________________
Date of Diagnosis ________________________________________________________________________________
Do you currently need another person’s help in performing any activities of daily living, such as
bathing dressing
toileting eating walking indoors transferring from bed to chair controlling
bladder or bowel functions
taking
medications as prescribed
? _________________________________________________________________
Name of Facility __________________________________________________________________________________
Date Entered
into
Facility
___________________________________________________________________________
Address ________________________________________________________________________________________
Telephone Number ________________________________________________________________________________
List services provided to residents
____________________________________________________________________
Does this facility have a provincial license? ___________________________ License Number ____________________
Do you own Long Term Care coverages of any kind with any other Insurance Company?
No
™Trade-marks of Royal Bank of Canada. RBC Life Insurance Company, licensee of trade-marks.
_____________________ _________________________________________________ ________________________
SIGNATURE OF CLAIMANT SOCIAL INSURANCE NUMBER
I authorize any health care professional, health or social service establishment, insurance company, the Medical
Information Bureau, financial institution, personal information agents or security agencies, my current employer or
any former employer and public body holding personal information concerning me, particularly medical information, to
supply this information to RBC Life Insurance Company and its reinsurers. Such information will be provided for
investigations necessary to adjudicate my claim or assess the validity of the policy as issued.
I understand that if I refuse to provide this information, RBC Life Insurance Company will be unable to adjudicate my
claim or assess the validity of the policy as issued.
A photocopy of the signed authorization to obtain this information will be as legally valid as the original.
This authorization will be valid until revoked by written notice to RBC Life Insurance Company.
DATE
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NOTICE OF FACILITY CARE (RBC Insurance)

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Completed 21 May 2021

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